An Open Letter To President Obama on Smoking

People talk about the power of cigarettes, how hard they are to give up, but they don't talk about what really makes them powerful, which is the most interesting part. While we know a lot about how to reliably help people quit, most smokers still struggle (often unsuccessfully) to become smoke-free. Millions of these smokers are like you, extremely self-disciplined. Even so they continue to struggle to stop the smoking habit. Surprisingly though, relatively small shifts in perceptions and thinking can help them lose interest in smoking permanently. Identifying and breaking up rote smoking habits (such as smoking with a certain friend) helps open up new, potentially more rewarding ways of living rather than just taking that cigarette. For example, you could start walking instead of smoking with your friend. The important thing is to shake up old patterns.

Mr. President, you can use your awareness as a tool to deal differently with the situations when you have the wish to smoke, and not let it become automatic. The capacity of our brains to solidify new learning from changes in behavior is truly phenomenal. The physical impact of changing habits is much greater than anyone ever imagined. Many smokers can also benefit from help with getting the most out of their stop smoking medicines, like nicotine replacement therapy. This was the case with a person I'll call Mark, and I'd like to tell you about his story.

Mark reported that the recognition of being hooked on cigarettes snuck up on him suddenly. He was even more surprised because last time he quit it was "no big deal." Now he was smoking a pack a day and couldn't pull himself out of it. It bothered him that he had "lost control" and it was "hard to let go." It also bothered him that he didn't "want to let go."

Mark worked in a demanding job doing a thousand things at once. He said he needed to smoke to cope with stress, which is the number one reason people give for smoking. He said smoking gives him a "break" and feels like a "great daydream." On the other hand, smoking also filled him with anxiety about "what's in a cigarette" and he wasn't enjoying it that much anymore. Back and forth his mind would go, holding onto completely incompatible ideas about smoking at the same time!

There is a widespread cultural belief among smokers that smoking relieves stress. Until they realize that smoking can't and doesn't help us deal with the things we need to do in our lives, they will continue to smoke.

Mark described how cold turkey, chantix, acupuncture and nicotine gum didn't work. He said he just didn't think he could quit (which is the number two reason smokers give for smoking).

The chemical addiction to smoking produces an emotional dependence and insecurity, a feeling you can't live without it. Smokers worry they can't quit. They worry when they will get the next cigarette. That's why it's helpful to remember that more people in the US have quit than currently smoke and most of them are getting along just fine without smoking. And if they are not fine, smoking is not the best medicine for whatever is ailing them.

Mark also spoke about his belief that smoking gives him peace (the third reason smokers give for smoking) even though he had become very uneasy and stressed about his smoking. In fact, he was constantly worried about it and associated picking up a cigarette with "whenever something happened at work." His smoking brain seemed to take every stressful moment as an opportunity to knock on the front door and ask to be invited in for a smoke.

So let's step back for a minute and look again at these three myths about smoking I have described in Mark's story. These thoughts are not unique to Mark, but are part of the typical mythology that surrounds smoking and quitting. Okay, back to Mark:

(1) he thought he smoked because of stress and yet it brought him stress.

(2) He thought smoking gave him peace and yet it made him uneasy.

(3) He didn't think he could quit, and then, like a losing team, he lost confidence.

Advice for before you quit:

Making the most of medicines, like nicotine replacement therapy (NRT) can effectively build your confidence to quit smoking. Smokers are often prescribed quit smoking medications in a casual manner, with little attention paid to the details of how best to use the nicotine patch, the gum or the oral inhaler as confidence builders. So here are three solutions that worked for Mark and may work for you:

(1) When using Nicotine Replacement Therapy, be careful not to use too little. How do you know how much is best to start off with? How do you measure nicotine so you know you are getting enough? Here is the secret: each cigarette delivers about 1 mg of nicotine regardless of brand or kind (menthol, low tar etc). Each smoker will extract about 1mg even if they have to puff harder to do it with some brands. So when you consider your starting point with NRT you can figure out how many mgs of nicotine you need based on how many cigarettes you smoke on average each day.

(2) There are differences among nicotine replacement products, and you need to make sure you are getting a full-strength dose to start out of the gate confidently. Know the difference between how each kind of NRT is labeled, what it delivers and how much nicotine you absorb. For example, the patch is the only form of NRT that delivers and absorbs the amount that is labeled. A 21 mg patch delivers 21 mgs of nicotine (which equals about a pack a day), usually over a 24-hour period. 4mg nicotine gum, on the other hand, delivers 4mg and you absorb 2mgs (which equals two cigarettes worth of nicotine). 2 mg nicotine gum delivers 2mg and you absorb 1mg (or one cigarette worth of nicotine). The nicotine oral inhaler is labeled 10mg, but delivers 4mg per cartridge and you absorb only 2mg (or about two cigarettes worth of nicotine per cartridge).

(3) Consider doubling up with two forms of NRT. Combining the patch and the gum or the patch and the nicotine inhaler, for example, has been shown in the most recent US government clinical practice guidelines to be the most successful medication strategy available! By putting on a patch you are getting a steady state of nicotine to lessen your withdrawal symptoms. By using the gum or the inhaler as needed, you are developing a ritual which can serve as an alternative behavior when you feel like smoking. It also helps to use the second form of
NRT when you are struggling or having tough times, especially in the first few smoke-free weeks.

So how did this work to help Mark? He began an aggressive nicotine replacement therapy (NRT) strategy: a 14 mg nicotine patch and three cartridges a day of a nicotine oral inhaler. While this helped to ease him out of his smoking routine, it also immediately built up his confidence and gave him hope that he could successfully solve his smoking problem.

When I next saw Mark, he was using his NRT according to plan and hadn't smoked for five days. Several weeks later he wasn't even thinking about smoking and was tempted to stop his NRT altogether.

I don't advise quitting the NRT too soon. Sometimes people stop the NRT just when it is working well and they are gaining confidence. Then as the withdrawal from cigarettes is fading, they are unprepared as the mind games begin, such as having "just one cigarette." NRT has a way of keeping you on the track as you begin to find your way confidently as a non-smoker. Mark was doing a good job of picking apart his excuses to smoke and finding it much easier this time.

Once you quit smoking completely and are feeling confident, remember, if the front door is closed, your smoking brain is always looking for a way to get in through the back door. Once you "smoke one" and let it back in, it quickly starts to dig in and take up residence in the less flexible parts of the brain that are wired to repeat rote experiences. The laws which make it difficult to smoke in public places now cover over half the American population. This has made it much easier on people who want to quit to avoid the powerful relapse trigger of being around other smokers in offices, bars and restaurants. Two out of three Americans no longer allow smoking in their homes. Secret, part-time, "intermittent" or "sneaking" smoking is on the rise as smokers try to adapt to the changing societal landscape which is no longer so welcoming. Many people who would have used nicotine gum to help get through a long plane ride are now using NRT as a way to cut down and control, not stop, smoking. NRT is a powerful tool but it works to heal the addiction to smoking only when you quit smoking completely. If you smoke even a little it is like feeding a beast that will only want more. On the other hand, if you go completely smoke-free, you will be starving the beast and healing physically and mentally from the addiction. This is the difference between training your smoking brain to wait for the next cigarette versus fully accepting that your smoking party is over for good.

Advice for after you quit:

(1) Be careful not to stop using NRT too soon. Many people delay quitting for years, and then finally once they'are working on breaking the habit, they are in a tearing hurry to get off the NRT. Sometimes the problem can be overconfidence. In fact, overconfidence and under-confidence are classic mistakes in using NRT. If you stop the NRT before you have made a secure adjustment to being smoke-free, the next time you face stress, or some other smoking trigger, you may be setting yourself up for a relapse. Under-confidence usually shows up as avoiding the smoking issue altogether out of fear you won't be successful anyway.

(2) Don't rely only on NRT to do the job. Choose in advance of your quit date your preferred behavioral strategies. Here are a few good tips that many people find helpful:

Drink water and carry around a water bottle or suck on ice cubes when at home.

Learn to breathe slowly and to relax deeply, especially when you need a work break, or after a task you have completed, or when you experience stress.

Avoid smoke and smokers, or work out an arrangement with them so you don't have to breathe their smoke. Smoking is contagious!

Limit or avoid alcohol, especially when you are first smoke-free, and especially if smoking and drinking often go together for you.

Remember to use your NRT at risky times when you might be tempted to smoke! It is always safer to use NRT than to smoke. Remember, if you aren't smoking, you are healing both mentally and physically. Knowing how to get the most out of NRT can make your smoke-free journey as pain-free as possible!

About Dr. Daniel Seidman: Dr. Seidman is author of the new book Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit with a foreward by Dr. Mehmet Oz (Fireside Trade Paperback Original, January 2010). Dr. Seidman first introduced his own program to stop smoking as a featured expert on The Oprah Winfrey Show with Dr. Oz early in 2008. For more details about the book go to www.danielfseidman.com.

Dr. Seidman is a clinical psychologist and director of the smoking cessation service at Columbia University Medical Center. For the past twenty years, he has done research on smoking and operated a variety of clinics in community settings, corporations, and at New York Presbyterian Hospital and Columbia University, in which countless patients have learned to quit smoking.